The analysis will focus on why the pilot lost situational awareness and confused the Expo buoy for the le Ste-Hlne buoy. Situational awareness can be defined as all the knowledge that is accessible and can be integrated into a coherent picture, when required, to assess and cope with a situation. To maintain situational awareness, a person scans for signals or cues which can be interpreted to reveal important information, such as location, speed, and the presence of hazards. A pilot who has the conduct of a vessel has to maintain situational awareness to navigate safely. When performing routine tasks, people can err when they do not attend to all the salient situational cues. Because they do not attend to all relevant cues, they are susceptible to confusing an object that looks like, is in the expected location and/or does a similar job, for the intended object. This error form has been identified as perceptual confusion, that is, during routine tasks, this type of perceptual error usually takes the form of accepting look-alikes for the intended object.(2) In this occurrence, the pilot, who was familiar with the area, focused his attention ahead. He was expecting to see the white light of the le Ste-Hlne buoy to confirm the vessel's position. The flashing white light that he noted on the port beam, however, was the light of the Expo buoy, which he confused with the light of the le Ste-Hlne buoy. The misidentification of the Expo buoy for the le Ste-Hlne buoy is consistent with perceptual confusion, in that the light of the Expo buoy looked like the light of the le Ste-Hlne buoy, it was in the expected location of the le Ste-Hlne buoy, and both buoys performed the same job of marking the channel. The perceptual confusion of the two buoys indicated that the pilot had experienced a loss of situational awareness, possibly influenced by the restricted visibility. These two buoys have different signalling sequences, but both are fitted with white lights. The first is a west cardinal light buoy marked Expo and is situated on the east side of the channel. Its characteristics [Q(9)W15s] are that of a group quick flashing white light with a group of 9 flashes regularly repeated 4 times per minute (every 15 seconds). The second buoy is a north cardinal light buoy marked le Ste-Hlne and is situated on the northern tip of le Sainte-Hlne. Its characteristics [Q1s] are that of a quick flashing white light in which a flash is regularly repeated at a rate of 60 flashes per minute (a flash every second). When the pilot saw the light of the Expo buoy, he mistook it for the light of the le Ste-Hlne buoy. He did not try to confirm his assessment of the situation, but took the action that seemed appropriate to him without using other means at his disposal to determine the position of the vessel. In this occurrence, although the pilot had the conduct of the vessel, the master was on the bridge following the vessel's progress on radar, and he judged it to be normal. The pilot made an unexpected alteration of course without informing the master of the situation. No one, however, objected to the course alteration, and no one challenged the order or asked the pilot to explain the reason for this manoeuvre which put the vessel in a precarious situation. Bridge Resource Management (BRM) principles and techniques encourage the use of all available resources to ensure a team approach for the safe completion of the operation. Had BRM practices been in effect, the pilot's misidentification of the one buoy for the other could have been averted.Analysis The analysis will focus on why the pilot lost situational awareness and confused the Expo buoy for the le Ste-Hlne buoy. Situational awareness can be defined as all the knowledge that is accessible and can be integrated into a coherent picture, when required, to assess and cope with a situation. To maintain situational awareness, a person scans for signals or cues which can be interpreted to reveal important information, such as location, speed, and the presence of hazards. A pilot who has the conduct of a vessel has to maintain situational awareness to navigate safely. When performing routine tasks, people can err when they do not attend to all the salient situational cues. Because they do not attend to all relevant cues, they are susceptible to confusing an object that looks like, is in the expected location and/or does a similar job, for the intended object. This error form has been identified as perceptual confusion, that is, during routine tasks, this type of perceptual error usually takes the form of accepting look-alikes for the intended object.(2) In this occurrence, the pilot, who was familiar with the area, focused his attention ahead. He was expecting to see the white light of the le Ste-Hlne buoy to confirm the vessel's position. The flashing white light that he noted on the port beam, however, was the light of the Expo buoy, which he confused with the light of the le Ste-Hlne buoy. The misidentification of the Expo buoy for the le Ste-Hlne buoy is consistent with perceptual confusion, in that the light of the Expo buoy looked like the light of the le Ste-Hlne buoy, it was in the expected location of the le Ste-Hlne buoy, and both buoys performed the same job of marking the channel. The perceptual confusion of the two buoys indicated that the pilot had experienced a loss of situational awareness, possibly influenced by the restricted visibility. These two buoys have different signalling sequences, but both are fitted with white lights. The first is a west cardinal light buoy marked Expo and is situated on the east side of the channel. Its characteristics [Q(9)W15s] are that of a group quick flashing white light with a group of 9 flashes regularly repeated 4 times per minute (every 15 seconds). The second buoy is a north cardinal light buoy marked le Ste-Hlne and is situated on the northern tip of le Sainte-Hlne. Its characteristics [Q1s] are that of a quick flashing white light in which a flash is regularly repeated at a rate of 60 flashes per minute (a flash every second). When the pilot saw the light of the Expo buoy, he mistook it for the light of the le Ste-Hlne buoy. He did not try to confirm his assessment of the situation, but took the action that seemed appropriate to him without using other means at his disposal to determine the position of the vessel. In this occurrence, although the pilot had the conduct of the vessel, the master was on the bridge following the vessel's progress on radar, and he judged it to be normal. The pilot made an unexpected alteration of course without informing the master of the situation. No one, however, objected to the course alteration, and no one challenged the order or asked the pilot to explain the reason for this manoeuvre which put the vessel in a precarious situation. Bridge Resource Management (BRM) principles and techniques encourage the use of all available resources to ensure a team approach for the safe completion of the operation. Had BRM practices been in effect, the pilot's misidentification of the one buoy for the other could have been averted. The vessel was transiting in the channel under the conduct of a pilot toward the Canal de la Rive Sud in restricted visibility. The light characteristics of the two buoys are different, but they are both fitted with a white light; this may lead to confusion in restricted visibility if the sequence of the flashes is not observed for at least 15 seconds. The pilot lost situational awareness and confused the light of the Expo buoy with the light of the le Ste-Hlne buoy. The pilot, who was familiar with the area, did not use the means at his disposal to confirm the vessel's position before ordering the course alteration. The master, who was following the vessel's progress on the radar screen, did not object to the pilot's order for hard-a-port helm. Although there was exchange of information between the pilot and the master during the transit, there was no discussion concerning the impromptu course alteration which led to the grounding.Findings The vessel was transiting in the channel under the conduct of a pilot toward the Canal de la Rive Sud in restricted visibility. The light characteristics of the two buoys are different, but they are both fitted with a white light; this may lead to confusion in restricted visibility if the sequence of the flashes is not observed for at least 15 seconds. The pilot lost situational awareness and confused the light of the Expo buoy with the light of the le Ste-Hlne buoy. The pilot, who was familiar with the area, did not use the means at his disposal to confirm the vessel's position before ordering the course alteration. The master, who was following the vessel's progress on the radar screen, did not object to the pilot's order for hard-a-port helm. Although there was exchange of information between the pilot and the master during the transit, there was no discussion concerning the impromptu course alteration which led to the grounding. The pilot, who had the conduct of the vessel, was not well aware of the situation and did not use the means at his disposal before ordering the course alteration. The pilot and the master did not consult with each other or exchange information to better assess the situation. The light characteristics of the two buoys are different, but they are both fitted with white lights; this may have led to confusion in restricted visibility if the sequence of the flashes was not observed carefully for at least 15 seconds.Causes and Contributing Factors The pilot, who had the conduct of the vessel, was not well aware of the situation and did not use the means at his disposal before ordering the course alteration. The pilot and the master did not consult with each other or exchange information to better assess the situation. The light characteristics of the two buoys are different, but they are both fitted with white lights; this may have led to confusion in restricted visibility if the sequence of the flashes was not observed carefully for at least 15 seconds. Following this occurrence, the Canadian Coast Guard decided to change the light characteristics of the buoys. The west cardinal light buoy marked Expo was changed to a port buoy, and the light characteristics of the north cardinal buoy marked le Ste-Hlne will be changed from [Q1s] to [VQ0.5s].Safety Action Taken Following this occurrence, the Canadian Coast Guard decided to change the light characteristics of the buoys. The west cardinal light buoy marked Expo was changed to a port buoy, and the light characteristics of the north cardinal buoy marked le Ste-Hlne will be changed from [Q1s] to [VQ0.5s].